Provider Demographics
NPI:1265850952
Name:GULLIVER, KRISTINA DEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:DEVIN
Last Name:GULLIVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N GRAHAM STREET
Mailing Address - Street 2:SUITE 265
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227
Mailing Address - Country:US
Mailing Address - Phone:503-282-7002
Mailing Address - Fax:503-280-1290
Practice Address - Street 1:501 N GRAHAM STREET
Practice Address - Street 2:SUITE 265
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227
Practice Address - Country:US
Practice Address - Phone:503-282-7002
Practice Address - Fax:503-280-1290
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9550276-12052080N0001X
WAMD.MD.610489112080N0001X
ORMD1980682080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty